Provider Demographics
NPI:1205197878
Name:WILSON, JONATHAN B (DPM)
Entity type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:B
Last Name:WILSON
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5020
Mailing Address - Street 2:
Mailing Address - City:GRAND ISLAND
Mailing Address - State:NE
Mailing Address - Zip Code:68802-5020
Mailing Address - Country:US
Mailing Address - Phone:308-381-0404
Mailing Address - Fax:
Practice Address - Street 1:620 N DIERS AVE STE 100
Practice Address - Street 2:
Practice Address - City:GRAND ISLAND
Practice Address - State:NE
Practice Address - Zip Code:68803-4985
Practice Address - Country:US
Practice Address - Phone:308-381-0404
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-31
Last Update Date:2012-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE334213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist